Nine years ago, Richard Langford reported to the hospital for routine knee replacement, expecting to return home in two or three days.
Under anesthesia, he aspirated contents from his stomach and was rushed to an intensive care unit (ICU), where he spent three weeks. He has no memory of that but recalls waking up a month after the operation, strapped to a gurney in a nursing home. People spoke. But the man who has a doctor of divinity, traveled the world in mission work, and spoke seven languages couldn’t make out their words.
Now, at age 62, Langford lives in Nashville, Tenn., with his 88-year-old mother. He speaks haltingly, and his conversation drifts. He suffers from anxiety and is prone to bouts of confusion, frustration, and anger. “I cry very easily. I don’t know where that comes from or why.”
Monday, July 17, 2017
Learn Serve Lead 2017: The AAMC Annual Meeting
LSL, scheduled for Nov. 3-7 in Boston, Mass., will feature sessions on patient safety and caring for the sickest populations:
Providing Safer Care Through Simulation-Enhanced Interprofessional Education (IPE), Monday, Nov. 6, 3:00–4:15 p.m. A brief review of the current science of simulation for IPE and examples of how simulation-enhanced IPE can improve patient safety, patient outcomes, and the experience of care.
Managing the Sickest of the Sick in an Accountable Environment, Monday, Nov. 6, 10:30–11:45 a.m. A discussion about the critical importance of academic health systems and providers in developing a better understanding of how to manage high-need/high-cost patients in an accountable, risk-based environment.
On his best days Langford said he can drive. On his worst, “I come in and sit in my chair and just hunker down all day long,” he said. “People think this goes away and you get healed and go on your merry way. But that’s not true. You’re stuck with this.”
, and at least half who survive treatment will suffer long-term disorders that were acquired or exacerbated by a combination of their initial illness and the treatment they received in an ICU. The symptoms can include debilitating muscle weakness, mobility problems, cognitive decline, and psychological problems. Both critical illness myopathy and lack of mental acuity can prolong the recovery process.
According to apublished in the New England Journal of Medicine, 58% of ICU survivors had significant cognitive impairment after one year. “This is a dementia that looks a lot like Alzheimer’s disease or traumatic brain injury,” said one of the study’s authors, Wes Ely, MD, MPH, professor of medicine and director of the at the Vanderbilt University School of Medicine. In addition, posttraumatic stress disorder affects 10% to 25% who receive ICU care and about one-third will suffer depression.
Two academic medical centers have been largely responsible for bringing PICS front and center, developing and testing new protocols both in the ICU and post discharge to reduce the ill effects of critical care. Indiana University Health and Vanderbilt University Medical Center created the nation’s first two critical care recovery centers for patients with PICS, along with programs to address prevention.
For decades, these aftereffects of critical care were largely overlooked because ICU activity was focused on sheer survival, said James Jackson, PsyD, neuropsychologist and assistant director of Vanderbilt’s ICU Recovery Center. “Now people say, it’s not enough that I survived. I’d like to be happy. I’d like to be functional. I’d like to have some degree of quality of life.”
Identifying and addressing risk factors
Delirium that emerges during critical care is perhaps the greatest risk of long-term problems to come. The use of sedatives to treat confused and agitated patients can lead to a cycle of delirium.
“For every additional day of delirium in the ICU, you have a 35% increased risk of long-term cognitive impairment.”
Wes Ely, MD, MPH
Vanderbilt University School of Medicine
“The longer you have delirium in the hospital—that acute problem of brain dysfunction—the more you’re going to have the PICS problem,” explained Ely. “For every additional day of delirium in the ICU, you have a 35% increased risk of long-term cognitive impairment.”
Another risk factor is the use of mechanical ventilation, which is associated with delirium. In addition, a study of mechanical ventilation in mice showed additional injury in the brain, similar to patients with delirium, said S. Jean Hsieh, MD, associate professor of clinical medicine at the Albert Einstein College of Medicine and Montefiore Medical Center.
Heavy sedation, especially with benzodiazepines, likewise increases the risk of delirium, which can portend long-lasting cognitive problems later.
A patient with dementia or Alzheimer disease or another cognitive impairment before ICU hospitalization has a greater risk of PICS, too.
Ely and his critical care colleagues have reported significant improvements in outcomes by addressing these PICS risk factors. His team developed the ABCDEF program to improve ICU protocols. The program involves strategies shown to reduce the risk factors for PICS in both old and young patients:
Assessing and managing pain
Both awakening patients and encouraging them to breathe on their own
Choices in sedatives and levels of sedation
Delirium—reducing it as much as possible
Early mobility and exercise
“We know that it improves survival; we know that it reduces time on mechanical ventilation; we know that it reduces delirium,” said Ely about the program. In a study of more than 6,000 patients in seven California community hospitals published this year in, Ely and colleagues showed “for every 10% increase in compliance with the A-to-F bundle, you got a 15% increase in survival and a 15% reduction in delirium and coma.”
Babar Khan, MD, MS, associate professor of medicine, Indiana University (IU) School of Medicine and medical director of the Eskenazi Health Critical Care Recovery Center, has used a similar protocol and seen rates of delirium go down over the past several years in critical care patients. Further studies will determine if the long-term effects of PICS go down as well.
The Montefiore Medical Center instituted the ABCDE program in stages, Hsieh says. The center is still working on the F—family—component. “We were able to reduce sedative use, we were able to reduce the prevalence of ICU delirium, and after we completed the entire bundle, we were able to show that we reduced ICU length of stay, hospital length of stay, and time on mechanical ventilation. We even reduced the total hospital cost. Patients and their families really appreciate the program,” Hsieh said.
Centers specializing in PICS are also changing practices once patients leave the hospital.
At the IU critical care facility, survivors receive cognitive, psychological, and physical assessment. A pharmacist reconciles new medications with any they were taking previously. A conference with the patient and family kicks off a personalized care plan for the next year. Khan said he is developing protocols that patients can start at home, including physical exercise and cognitive training.
For Vanderbilt ICU patients, said Jackson, “The focus is on rapid identification of new problems that people weren’t aware that they had, referral to specialists that they previously would not have known that they needed, and in many cases, ongoing therapy or assessment.” Langford participates today in an ICU survivors support group created at Vanderbilt.
As simple as ABCDEF
Many ICUs—more than 1,000, according to Jackson—are adopting Vanderbilt’s ABCDEF program or something similar. But with close to 5,700 acute care hospitals in the country, all with at least one ICU, there’s room for improvement.
“We want to maximize human dignity, and having somebody have a more functional brain, a more functional body—that’s what really drives us,” said Ely.
That means persuading doctors and other staff to change deeply ingrained practices. “What we know is that some ICUs do this very well and some ICUs don’t,” said Ely. He suggested hospitals work in stages to increase the number patients benefitting from ABCDEF.
Jackson said that using “metrics that insurance companies care about” can speed the process. “Not only demonstrating that lives are improved in a subjective way, but that fewer patients are being readmitted—this could really get the attention of health care systems and galvanize support for follow-up clinics.”
The challenge of PICS will grow as Americans age and require intensive care as a result of ailments ranging from heart attacks to sepsis. “This is not an issue which we can just ignore,” said Khan. “We’re going to see more of it in the years to come.”